208
Original Investigation
Comparison of two different laparoscopic hysterectomies: laparoscopic hysterectomy vs. total laparoscopic hysterectomy Farkl× iki laparoskopik histerektomi tekniùinin karü×laüt×r×lmas×: laparoskopik histerektomi ve total laparoskopik histerektomi Mert Göl1, Ayüen K×z×lyar2 1 Department of Obstetrics and Gynecology, Medical School, Çanakkale Onsekiz Mart University, Çanakkale, Turkey 2 Department of Obstetrics and Gynecology, Gazi Hospital, úzmir, Turkey
Abstract
Özet
Objective: The aim of this study was to compare the efficacy and safety of laparoscopic hysterectomy (LH) and Total Laparoscopic Hysterectomy (TLH). Methods: Both types of hysterectomy were performed by retroperitoneal uterine artery sealing using LigaSure™ by four-puncture. A total of 45 patients were operated on by LH and 22 by TLH. The mean operation time, amount of intraoperative bleeding, drop in hemoglobin concentration, weight of removed uterus, major and minor per-post operative complications, and rate of conversion to the classical abdominal approach in the two groups were compared. Results: The mean operation time in TLH (110 min.) was significantly longer than in LH (65 min.). This was mainly due to the shorter mean operating time in the vaginal part of LH group (13 min.) compared to laparoscopic dissection of uterosacral ligaments and vaginal suturing (42 min.) in the TLH group. Median blood loss was also significantly higher in the TLH group (278 ml.) compared to the LH group (110 ml.). There were no significant differences in the mean drop of hemoglobin concentration, uterine weight, major and minor complications and conversion to laparotomy between the groups. Conclusion: LH seems to be a faster and more demanding method than TLH. With its shorter operation time and less bleeding, LH may be preferred to TLH. (J Turkish-German Gynecol Assoc 2010; 11: 208-11) Key words: Laparoscopy, hysterectomy, laparoscopic hysterectomy, total laparoscopic hysterectomy
Amaç: Laparoskopik histerektomi (LH) ile Total laparoskopik histerektomi (TLH) tekniklerinin etkinliùi ve güvenilirliùini karü×laüt×rmak. Gereç ve Yöntemler: Her iki tip laparoskopik histerektomi dört port ve LigaSure™ kullan×larak retroperitoneal uterin arter mühürleme yöntemi ile yap×ld×. Toplam 45 hasta LH ile ameliyat edilirken, 22 hasta TLH ile ameliyat oldu. Gruplar aras×nda ortalama operasyon süresi, intraoperative kanama miktar×, hemoglobin de düüüü, uterus aù×rl×ù×, major ve minor ameliyat komplikasyonlar×, ve laparotomi konversiyon oranlar× karü×laüt×r×ld×. Bulgular: TLH uygulanan grupta ortalama operasyon süresi (110 dk.) LH uygulanan gruba göre (65 dk) anlaml× olarak k×sa bulundu. Bu fark×n nedeni LH grubundaki vajinal etab×n (13 dk.), TLH grubundaki uterosakral, kardinal ligamentlerin disseksiyonu ve laparoskopik vajinal sutur uygulama süresine oranla (42 dk.) anlaml× olarak daha k×sa sürmesidir. Ortalama kan kayb× TLH grubunda (278 ml.), LH grubuna gore (110 ml.) anlaml× olarak daha fazla bulunmuütur. Gruplar aras×nda ortalama hemoglobin düzeyinin düüüüünde, uterus aù×rl×ù×nda, major ve minör komplikasyonlarda ve laparotomi konversiyon oranlar×nda anlaml× bir farkl×l×k tespit edilmemiütir. Sonuç: LH, TLH’ye nazaran daha h×zl× ve güvenilir bir cerrahi metod gibi görünmektedir. Özellikle daha k×sa ameliyat süresi ve daha az kanama miktar× nedeniyle TLH yerine LH’yi tercih etmeliyiz. (J Turkish-German Gynecol Assoc 2010; 11: 208-11) Anahtar kelimeler: Laparoskopi, histerektomi, laparoskopik histerektomi, total laparoscopik histerektomi
Received: 15 August, 2010
Geliü Tarihi: 15 Aùustos 2010
Accepted: 23 October, 2010
Introduction After cesarean section hysterectomy is the second most common gynecologic operation performed worldwide (1). Although hysterectomy can be conducted by mini-laparotomy, the vast majority are performed by a laparotomy with a 8-10 cm incision which enables the patients to tolerate more pain and discomfort compared with the vaginal or laparoscopic routes (2). It is well known that vaginal hysterectomy should be offered to the patient as the first line surgical
Kabul Tarihi: 23 Ekim 2010
method for removing her uterus (3, 4). However, vaginal hysterectomy is performed in 50% of patients even in the hands of experienced surgeons because of the limitations due to a large uterus, no previous vaginal delivery, adnexal mass and a history of previous abdominal operation (5). Laparoscopic hysterectomy (LH) is performed much less frequently. There are different types of classifications for LH. However, more recently, three sub-categorisations of LH have been described by Reich et al., (6) which are as follows. (i) Laparoscopic assisted vaginal hysterectomy (LAVH), where
Address for Correspondence / Yaz×üma Adresi: Mert Göl, M.D., Department of Obstetrics and Gynecology, Medical School, Çanakkale Onsekiz Mart University, Çanakkale, Turkey Phone: +90 286 218 00 18 Fax: +90 286 218 03 93 e.mail: [email protected] doi:10.5152/jtgga.2010.39
Göl et al. Laparoscopic hysterectomy is a safe and fast surgical modality
J Turkish-German Gynecol Assoc 2010; 11: 208-11
part of the hysterectomy is performed by laparoscopic surgery and part vaginally, but the laparoscopic component of the operation does not involve division of the uterine vessels.(ii) LH, where the uterine vessels are ligated laparoscopically but part of the operation is performed vaginally. (iii) Total laparoscopic hysterectomy (TLH), where the entire operation (including suturing of the vaginal vault) is performed laparoscopically and there is no vaginal component. We believe that division of the uterine arteries is the most important part of LH. In a recent study we have shown that, when this step is managed laparoscopically, there is less bleeding and fewer complications (7). According to our experience over 300 laparoscopic hysterectomies in 3 years, we have noticed that there is significant amount of bleeding in the vaginal step of LAVH compared to LH and TLH (unpublished data). Therefore, we suggest that LAVH should be performed by endoscopic surgeons who are inexperienced in laparoscopic hysterectomy and as soon as possible they should progress to LH or TLH. However, it is still not well known whether TLH offers any benefits or disadvantages over LH. This question has not been resolved in recent years and we still do not know which method is best. Accordingly, the aim of the present work was to try to determinel the best method for hysterectomy laparoscopy, TLH or LH.
209
Figure 1. The LigaSure™ V 5 mm (B) is grasping the uterine artery (C) between the internal iliac artery (A) and ureter (D). Note that the suction device is pulling the ureter medially to prevent any damage during sealing
Materials and Methods Intraoperative and postoperative data of both groups were analyzed retrospectively. In time, TLH was performed in all patients instead of LH. Both types of hysterectomy were performed under general anaesthesia with the technique described previously by Köhler et al.,(7). However, in contrast to these authors we used LigaSure™ V 5 mm (Valley lab) to seal and cut the uterine vessels instead of using the bipolar cautery (Fig. 1) and infundibulopelvic ligaments (Fig. 2). In the vaginal step of the LH procedure, Ligasure Vmax was used. In TLH uterosacral and cardinal ligaments were also sealed and cut with the Ligasure followed by a circular incision of the vagina using the hook unipolar cautery. The vagina was also sutured laparoscopically in TLH. All operations were performed in the lithotomy position and the drain was only used when indicated. Total operating time (from the maintainence of pneumoperitoneum to vaginal cuff closure), the duration of the vaginal step in LH and also duration of uterosacral and cardinal ligaments dissection within vaginal cuff closure in TLH, estimated blood loss, mean drop in Hb concentration, uterine weight, rate of intraoperative and post-operative complications, conversion from laparoscopy to the classic abdominal approach, use of blood transfusion and duration of hospital stay were recorded and analyzed. Blood loss was measured by recording the contents of the fluid extraction device. We used the fluid extraction device during the vaginal step, without any surgical pads. Statistical analysis Statistical Analysis was performed using the SPSS ver. 11 (Chicago- IL). Median, medium and percentages of the variables were analyzed. The differences between the two groups were analyzed by Chi – Square test or Mann Whitney U test. A p value
Original Investigation
Comparison of two different laparoscopic hysterectomies: laparoscopic hysterectomy vs. total laparoscopic hysterectomy Farkl× iki laparoskopik histerektomi tekniùinin karü×laüt×r×lmas×: laparoskopik histerektomi ve total laparoskopik histerektomi Mert Göl1, Ayüen K×z×lyar2 1 Department of Obstetrics and Gynecology, Medical School, Çanakkale Onsekiz Mart University, Çanakkale, Turkey 2 Department of Obstetrics and Gynecology, Gazi Hospital, úzmir, Turkey
Abstract
Özet
Objective: The aim of this study was to compare the efficacy and safety of laparoscopic hysterectomy (LH) and Total Laparoscopic Hysterectomy (TLH). Methods: Both types of hysterectomy were performed by retroperitoneal uterine artery sealing using LigaSure™ by four-puncture. A total of 45 patients were operated on by LH and 22 by TLH. The mean operation time, amount of intraoperative bleeding, drop in hemoglobin concentration, weight of removed uterus, major and minor per-post operative complications, and rate of conversion to the classical abdominal approach in the two groups were compared. Results: The mean operation time in TLH (110 min.) was significantly longer than in LH (65 min.). This was mainly due to the shorter mean operating time in the vaginal part of LH group (13 min.) compared to laparoscopic dissection of uterosacral ligaments and vaginal suturing (42 min.) in the TLH group. Median blood loss was also significantly higher in the TLH group (278 ml.) compared to the LH group (110 ml.). There were no significant differences in the mean drop of hemoglobin concentration, uterine weight, major and minor complications and conversion to laparotomy between the groups. Conclusion: LH seems to be a faster and more demanding method than TLH. With its shorter operation time and less bleeding, LH may be preferred to TLH. (J Turkish-German Gynecol Assoc 2010; 11: 208-11) Key words: Laparoscopy, hysterectomy, laparoscopic hysterectomy, total laparoscopic hysterectomy
Amaç: Laparoskopik histerektomi (LH) ile Total laparoskopik histerektomi (TLH) tekniklerinin etkinliùi ve güvenilirliùini karü×laüt×rmak. Gereç ve Yöntemler: Her iki tip laparoskopik histerektomi dört port ve LigaSure™ kullan×larak retroperitoneal uterin arter mühürleme yöntemi ile yap×ld×. Toplam 45 hasta LH ile ameliyat edilirken, 22 hasta TLH ile ameliyat oldu. Gruplar aras×nda ortalama operasyon süresi, intraoperative kanama miktar×, hemoglobin de düüüü, uterus aù×rl×ù×, major ve minor ameliyat komplikasyonlar×, ve laparotomi konversiyon oranlar× karü×laüt×r×ld×. Bulgular: TLH uygulanan grupta ortalama operasyon süresi (110 dk.) LH uygulanan gruba göre (65 dk) anlaml× olarak k×sa bulundu. Bu fark×n nedeni LH grubundaki vajinal etab×n (13 dk.), TLH grubundaki uterosakral, kardinal ligamentlerin disseksiyonu ve laparoskopik vajinal sutur uygulama süresine oranla (42 dk.) anlaml× olarak daha k×sa sürmesidir. Ortalama kan kayb× TLH grubunda (278 ml.), LH grubuna gore (110 ml.) anlaml× olarak daha fazla bulunmuütur. Gruplar aras×nda ortalama hemoglobin düzeyinin düüüüünde, uterus aù×rl×ù×nda, major ve minör komplikasyonlarda ve laparotomi konversiyon oranlar×nda anlaml× bir farkl×l×k tespit edilmemiütir. Sonuç: LH, TLH’ye nazaran daha h×zl× ve güvenilir bir cerrahi metod gibi görünmektedir. Özellikle daha k×sa ameliyat süresi ve daha az kanama miktar× nedeniyle TLH yerine LH’yi tercih etmeliyiz. (J Turkish-German Gynecol Assoc 2010; 11: 208-11) Anahtar kelimeler: Laparoskopi, histerektomi, laparoskopik histerektomi, total laparoscopik histerektomi
Received: 15 August, 2010
Geliü Tarihi: 15 Aùustos 2010
Accepted: 23 October, 2010
Introduction After cesarean section hysterectomy is the second most common gynecologic operation performed worldwide (1). Although hysterectomy can be conducted by mini-laparotomy, the vast majority are performed by a laparotomy with a 8-10 cm incision which enables the patients to tolerate more pain and discomfort compared with the vaginal or laparoscopic routes (2). It is well known that vaginal hysterectomy should be offered to the patient as the first line surgical
Kabul Tarihi: 23 Ekim 2010
method for removing her uterus (3, 4). However, vaginal hysterectomy is performed in 50% of patients even in the hands of experienced surgeons because of the limitations due to a large uterus, no previous vaginal delivery, adnexal mass and a history of previous abdominal operation (5). Laparoscopic hysterectomy (LH) is performed much less frequently. There are different types of classifications for LH. However, more recently, three sub-categorisations of LH have been described by Reich et al., (6) which are as follows. (i) Laparoscopic assisted vaginal hysterectomy (LAVH), where
Address for Correspondence / Yaz×üma Adresi: Mert Göl, M.D., Department of Obstetrics and Gynecology, Medical School, Çanakkale Onsekiz Mart University, Çanakkale, Turkey Phone: +90 286 218 00 18 Fax: +90 286 218 03 93 e.mail: [email protected] doi:10.5152/jtgga.2010.39
Göl et al. Laparoscopic hysterectomy is a safe and fast surgical modality
J Turkish-German Gynecol Assoc 2010; 11: 208-11
part of the hysterectomy is performed by laparoscopic surgery and part vaginally, but the laparoscopic component of the operation does not involve division of the uterine vessels.(ii) LH, where the uterine vessels are ligated laparoscopically but part of the operation is performed vaginally. (iii) Total laparoscopic hysterectomy (TLH), where the entire operation (including suturing of the vaginal vault) is performed laparoscopically and there is no vaginal component. We believe that division of the uterine arteries is the most important part of LH. In a recent study we have shown that, when this step is managed laparoscopically, there is less bleeding and fewer complications (7). According to our experience over 300 laparoscopic hysterectomies in 3 years, we have noticed that there is significant amount of bleeding in the vaginal step of LAVH compared to LH and TLH (unpublished data). Therefore, we suggest that LAVH should be performed by endoscopic surgeons who are inexperienced in laparoscopic hysterectomy and as soon as possible they should progress to LH or TLH. However, it is still not well known whether TLH offers any benefits or disadvantages over LH. This question has not been resolved in recent years and we still do not know which method is best. Accordingly, the aim of the present work was to try to determinel the best method for hysterectomy laparoscopy, TLH or LH.
209
Figure 1. The LigaSure™ V 5 mm (B) is grasping the uterine artery (C) between the internal iliac artery (A) and ureter (D). Note that the suction device is pulling the ureter medially to prevent any damage during sealing
Materials and Methods Intraoperative and postoperative data of both groups were analyzed retrospectively. In time, TLH was performed in all patients instead of LH. Both types of hysterectomy were performed under general anaesthesia with the technique described previously by Köhler et al.,(7). However, in contrast to these authors we used LigaSure™ V 5 mm (Valley lab) to seal and cut the uterine vessels instead of using the bipolar cautery (Fig. 1) and infundibulopelvic ligaments (Fig. 2). In the vaginal step of the LH procedure, Ligasure Vmax was used. In TLH uterosacral and cardinal ligaments were also sealed and cut with the Ligasure followed by a circular incision of the vagina using the hook unipolar cautery. The vagina was also sutured laparoscopically in TLH. All operations were performed in the lithotomy position and the drain was only used when indicated. Total operating time (from the maintainence of pneumoperitoneum to vaginal cuff closure), the duration of the vaginal step in LH and also duration of uterosacral and cardinal ligaments dissection within vaginal cuff closure in TLH, estimated blood loss, mean drop in Hb concentration, uterine weight, rate of intraoperative and post-operative complications, conversion from laparoscopy to the classic abdominal approach, use of blood transfusion and duration of hospital stay were recorded and analyzed. Blood loss was measured by recording the contents of the fluid extraction device. We used the fluid extraction device during the vaginal step, without any surgical pads. Statistical analysis Statistical Analysis was performed using the SPSS ver. 11 (Chicago- IL). Median, medium and percentages of the variables were analyzed. The differences between the two groups were analyzed by Chi – Square test or Mann Whitney U test. A p value
